Effective Date: January 1, 2021

Last Updated: December 21, 2020

Purpose:
This policy provides reimbursement and billing guidelines for doula services.

Scope:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Doula: A trained professional who provides continuous physical, emotional, and informational support throughout the perinatal period. Doulas are non-clinical providers, therefore, a doula cannot replace a trained, licensed medical professional, and cannot perform clinical tasks. Research shows that doula care is associated with better birth outcomes, including reductions in cesarean section rates.

Policy:
Horizon NJ Health will consider for reimbursement doula services consisting of prenatal visits, labor and delivery visits, and postpartum visits to eligible pregnant members.

Horizon NJ Health will cover either standard doula care or enhanced doula care.

• Standard doula care is comprised of up to 8 visits total during the prenatal or postpartum period, which includes 1 initial prenatal visit, as well as attendance at the delivery.
• Enhanced doula care, which is applicable only to members 19 years or younger at the time of the initial doula service, is comprised of up to 12 visits total during the prenatal or postpartum period, which includes 1 initial prenatal visit, as well as attendance at the delivery.

Eligible certified doulas must bill the appropriate CPT code(s), appended with modifier -HD, as well as modifiers -21 and/or -22 as applicable based on the service(s) rendered. All claims for doula services must include the diagnosis code Z32.2 (encounter for childbirth instruction) in order to be considered for payment.

Reimbursement for doula visits in the prenatal and postpartum periods are billed in 15-minute units, not to exceed the above maximum units per visit. Reimbursement for attendance at delivery is at a flat rate for both vaginal and cesarean deliveries. No additional reimbursement will be made for non-singleton births.

Multiple visits are not allowed in the same day except for the following instances:

• A prenatal doula visit occurs early in the day, and an L&D doula visit later in the day.
• A L&D doula visit occurs early in the day, and a postpartum doula later in the day.

Doula services can only be provided in the community, in clinicians’ offices (if a doula is accompanying the member to a clinician’s visit), or in the hospital.

Claims for doula services may be submitted to Horizon up to 365 days after the date of service.

Procedure:
Horizon NJ Health will consider for reimbursement doula service codes only when appended with modifier –HD and diagnosis code Z32.2.

Horizon NJ Health will consider for reimbursement doula services up to the maximum units allowed per visit as noted in this policy.

Horizon NJ Health will accept claims for doula services up to 365 days from the date of service.

Resources:
Budget and New Jersey law (P.L. 2019, c 85)

State of New Jersey, Department of Human Services, Division of Medial Assistance and Health Services, Doula Benefit Guidance (November 5, 2020)

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

History:

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.